II. Grading: Immunosuppressants

  1. High Level Immunosuppression
    1. Biological Agent (e.g. Humira)
    2. Prednisone dose >=20 mg/day for >=14 days
  2. Low Level Immunosuppression
    1. Prednisone dose <=20 mg/day
  3. Minimal Immunosuppression (should not impact Immunization, may receive live Vaccination)
    1. Prednisone for <14 days

III. Precautions

  1. Inactivated Vaccines
    1. Not harmful, but immunodeficient patients may have reduced immunogenic response to Vaccines
    2. Best to time inactivated Vaccines at least 2 weeks before starting immunosuppressants
    3. Do not delay indicated Vaccines in patients already immunodeficient
    4. Shingrix is safe in low Level Immunosuppression
      1. Shingrix efficacy and safety data are lacking in 2019, for those on High Level Immunosuppression
  2. Live Vaccines
    1. See Live Attenuated Vaccine
    2. Avoid Live Vaccines (e.g. MMR, Varicella) for those on high level immunosuppression
      1. Live Vaccines are best given at least 4 weeks before starting immunosuppression
    3. Do not use Flumist (Live Attenuated Influenza Vaccine) for immunocompromised patients
      1. Use inactivated infuenza Vaccine instead
    4. Do not use Zostavax (live Shingles Vaccine) in HIV Infection or high level immunosuppression
      1. Shingrix (recombinant, inactivated Vaccine released 2018) has replaced Zostavax and is preferred
      2. See Zostavax for indications (e.g. prior to immunosuppression medications)

IV. Prevention: Routine Vaccinations Recommended for patients on Immunosuppression

  1. Influenza Vaccine yearly
  2. Prevnar 13 (followed by Pneumovax 23 at least 8 weeks later)
    1. Immunocompromised adults >=19 years old
  3. Gardasil 9
    1. Give 3 doses (instead of 2 doses as used in standard series)

V. References

  1. (2019) Presc Lett 26(12): 68
  2. (2014) Presc Lett 21(2): 10

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